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THE doctor was dumbfounded: a drug that used to cost $50 was now selling for $28,000 for a 5-milliliter vial.
The physician, Dr. Ladislas Lazaro IV, remembered occasionally prescribing this anti-inflammatory, named H.P. Acthar Gel, for gout back in the early 1990s. Then the drug seemed to fade from view. Dr. Lazaro had all but forgotten about it, until a sales representative from a company called Questcor Pharmaceuticals appeared at his office and suggested that he try it for various rheumatologic conditions.
"I've never seen anything like this," Dr. Lazaro, a rheumatologist in Lafayette, La., says of the price increase.
How the price of this drug rose so far, so fast is a story for these troubled times in American health care — a tale of aggressive marketing, questionable medicine and, not least, out-of-control costs. At the center of it is Questcor, which turned the once-obscure Acthar into a hugely profitable wonder drug and itself into one of Wall Street's highest fliers.
At least until recently, that is. Now some doctors, insurance companies and investors are beginning to have doubts about whether the drug is really any better than much cheaper alternatives. Short-sellers have written scathing criticisms of the company, questioning its marketing tactics and predicting that its shareholders are highly vulnerable.
That Acthar is even a potential blockbuster is a remarkable turn of events, considering that the drug was developed in the 1950s by a division of Armour & Company, the meatpacking company that once ruled the Union Stock Yards of Chicago. As in the 1950s, Acthar is still extracted from the pituitary glands of slaughtered pigs — essentially a byproduct of the meatpacking industry.
The most important use of Acthar has been to treat infantile spasms, also known as West syndrome, a rare, sometimes fatal epileptic disorder that generally strikes before the age of 1.
For several years, Questcor, which is based in Anaheim, lost money on Acthar because the drug's market was so small. In 2007, it raised the price overnight, to more than $23,000 a vial, from $1,650, bringing the cost of a typical course of treatment for infantile spasms to above $100,000. It said it needed the high price to keep the drug on the market.
"We have this drug at a very high price right now because, really, our principal market is infantile spasms," Don M. Bailey, Questcor's chief executive, told analysts in 2009. "And we only have about 800 patients a year. It's a very, very small — tiny — market."
Companies often charge stratospheric prices for drugs for rare diseases — known as orphan drugs — and Acthar's price is not as high as some. Society generally tolerates those costs to encourage drug companies to develop crucial, possibly lifesaving drugs for these often neglected diseases.
But Questcor did almost no research or development to bring Acthar to market, merely buying the rights to the drug from its previous owner for $100,000 in 2001. And while the manufacturing of Acthar is complex, it accounts for only about 1 cent of every dollar that Questcor charges for the drug.
Moreover, the tiny "orphan" market soon became much bigger. Before long, Questcor began marketing the drug for multiple sclerosis, nephrotic syndrome and rheumatologic conditions, even though there is little evidence that Acthar is more effective for those other conditions than alternatives that are far cheaper. And the company did so without being required to prove that the drug actually works. That is because Acthar was approved for use in 1952, before the Food and Drug Administration required clinical trials to show a drug is effective for a particular disease. Acthar is essentially grandfathered in.
Today, only about 10 percent of the drug's sales are for infantile spasms. The new uses, Mr. Bailey has told analysts, represent multibillion-dollar opportunities for Acthar and Questcor, its sole maker.
The results have been beyond even the company's wildest dreams. Sales of Acthar, which accounts for essentially all of Questcor's sales, totaled nearly $350 million in the first nine months this year, up 145 percent from the period a year earlier. In the same period, Questcor's earnings per share nearly tripled, to $2.12. In the five years after the big Acthar price increase in August 2007, Questcor shares rose from around 60 cents to about $50, in one of the best performances of any stock in any industry.
But in September, the shares plummeted after Aetna, the big insurer, said it would no longer pay for Acthar, except to treat infantile spasms, because of lack of evidence the drug worked for other diseases. The stock now trades at $26.93.
Peter Wickersham, senior vice president for cost of care at Prime Therapeutics, a pharmacy benefits manager that has found the drug is possibly being overused, says the huge increase in Acthar's price for patients "just invites the type of scrutiny that it's received."
Questcor, meanwhile, has disclosed that the United States attorney's office in Philadelphia is investigating its marketing practices. The company hasn't been accused of wrongdoing.
Mr. Bailey, Questcor's C.E.O., defends his company's practices. He says that when Questcor raised Acthar's price, it did not initially intend to market the drug for other uses. It simply responded to demand. "Nobody predicted this," he said. "Nobody."
He also says that Questcor isn't competing with low-price alternatives, but that it is marketing the drug as a treatment when those alternatives fail. Used that way — for instance, as a last chance to avert kidney failure — insurers are still paying for the drug at least 85 percent of the time, he says.
Still, given that Questcor is now pursuing billion-dollar opportunities far beyond the treatment of infantile spasms, is the high, orphan-drug price still justified?
"We could lower the price and make less money," Mr. Bailey says, "and then we would be sued by our shareholders."
Whatever the case, one group of shareholders has done pretty well for itself. Over the last two years, as the company's share price mainly soared, Questcor insiders have sold more than $100 million of stock.
THE story of Questcor's wonder drug begins in Rochester, Minn. It was there, at the Mayo Clinic, that Dr. Philip S. Hench spent more than 20 years searching for what he called Substance X.
Dr. Hench, a rheumatologist, hypothesized that the body could make a compound that stilled the immune system's attacks on the joints of people with rheumatoid arthritis.
It turned out that another Mayo researcher, Dr. Edward C. Kendall, had isolated six hormones made by the adrenals, the small glands atop the kidneys that are chiefly responsible for releasing stress hormones. When a few patients were injected with one of the hormones in 1948, their symptoms subsided.
But that hormone, now known as cortisone, was then hard to synthesize. So Dr. Hench thought of injecting another substance that would stimulate the body to produce its own cortisone and othersteroid hormones. That substance was adrenocorticotropic hormone, or ACTH, which is made by the pituitary gland.
Dr. Hench obtained some ACTH from the Armour meatpacking company, which was extracting it from pigs as part of an effort to develop markets for leftover animal parts. (Its big success was Dial soap, introduced in 1948.)
When ACTH was injected into the first arthritis patient in February 1949, the results were as good as with cortisone, spurring a huge spike in demand for animal glands. By 1950, thousands of patients, not only those with arthritis but also those with gout, lupus, ulcerative colitis and many other diseases, had been treated with either cortisone or ACTH.
That year, Dr. Hench, Dr. Kendall and a third scientist were awarded the Nobel Prize in medicine.
In 1952, Armour won approval from the F.D.A. for H.P. Acthar Gel, or "highly purified" ACTH mixed with gelatin (another animal byproduct) to make it last longer in the body and require fewer injections. The label said the drug could be used to treat about 50 diseases.
But by the 1980s, drug companies had learned to synthesize steroids like prednisone, and those became the treatment of choice. In 1995, when the F.D.A. found numerous quality control problems at the factory manufacturing Acthar, the drug's owner at the time, Rhône-Poulenc Rorer, decided to discontinue the product rather than invest in manufacturing improvements.
That decision provoked an outcry from some patient groups and pediatric neurologists, who said the drug was the best treatment for infantile spasms. So Rhône-Poulenc, which became Aventis after a merger, continued to make a limited supply that was rationed to treat only infantile spasms or severe flare-ups of multiple sclerosis. With Aventis losing several million dollars a year on the drug, on sales of only about a half-million dollars, the company looked for a way out.
It sold the drug in 2001 to Questcor for $100,000 as well as a 1 percent royalty on annual sales over $10 million. At the time, Questcor, formed by a merger of two small companies in 1999, was losing money and looking for drugs to market. With help from Aventis, Questcor set up its own, somewhat more modern manufacturing through a contractor on Prince Edward Island, Canada.
Questcor immediately raised the price of Acthar to $700 a vial, from $40, and the price rose gradually after that. By the end of 2006, Acthar sales were about $12 million a year, but the company was still losing money.
In May 2007, James L. Fares, left as chief executive and was replaced, initially on an interim basis, by Mr. Bailey, who had joined the board a year earlier. A mechanical engineer by training, Mr. Bailey had retired in 2000 from a 10-year run as chief executive of Comarco, a military contractor and telecommunications concern.
Three months later, Questcor announced the huge price jump, aimed at repositioning Acthar as a specialty drug. The move prompted protests from parents and pediatric neurologists.
"It made us so sick to the stomach — just the fact that something like that could happen overnight with a drug my child needed to live," says Christina Culver of Colorado Springs. "It's just like someone saying, 'I'm going to charge you for oxygen now.' "
Ms. Culver's son Tyler was in the hospital, being treated for infantile spasms, just as the price increase hit. Tyler was due to leave the hospital, and Ms. Culver and her husband, Randy, were to continue the injections at home. Then the Culvers' insurer, Blue Cross Blue Shield, refused to pay the new high price. After a storm of publicity, the insurer backed down.
Questcor, however, hasn't, and has continued to raise the price, now at more than $28,400 a vial. Insurers generally pay for Acthar because it is considered the best treatment for infantile spasms. They also tend to pay for other approved uses if cheaper drugs have been tried first. And Questcor has carefully executed the orphan-drug playbook. Patients who cannot pay are given the drug free. The company helps with insurance co-payments, to make sure that a patient's inability to make a co-payment doesn't stand in the way of the drug being used and the insurer paying $28,000 a vial.
In other words, Questcor shifts the cost onto insurance companies while staving off consumer protests. It has a staff of 30 people who do nothing but work on insurance reimbursements — about one staff member for each of the roughly 30 prescriptions it gets in a typical day for all uses.
Questcor executives argue that with the free drug program and the ample supply, patients have better access to Acthar now than when it was cheaper and often in short supply.
"We believe we've been good stewards of this product," Mr. Bailey says.
Dr. Lawrence Brown, a neurologist at the Children's Hospital of Philadelphia and the president of the Child Neurology Foundation, says of Questcor: "They have gone out of their way to help every kid who needs the medicine to get it quickly and efficiently."
This year, the foundation awarded its first corporate citizenship award to Questcor. Dr. Brown says Questcor's donations — the amount has not been disclosed — to the foundation didn't influence the award.
STILL, the price remains a sticking point.
At Children's National Medical Center in Washington, "we've been instructed not to hospitalize a child with spasms unless the authorization has been procured to pay for it," said Dr. Phillip L. Pearl, chief of child neurology. In practice, however, no child has been turned away.
Dr. Shaun Hussain of Mattel Children's Hospital in Los Angeles said that the studies showing Acthar to be better than far cheaper steroids used too low a dose of steroids.
At his hospital, he reported at a medical meeting this month, 18 of 30 babies were successfully treated with two weeks' worth of a high-dose oral steroid. Only the 12 who did not respond were switched to Acthar, with five of them successfully treated.
Given that the steroids cost $200 for each baby, compared with about $125,000 for Acthar, the approach saved more than $2 million. "We have to look at the cost to the health care system," Dr. Hussain said.
Mr. Bailey says the new price was set to make the company viable based solely on sales for infantile spasms. Executives assumed at the time that the high price would preclude other uses.
But to Questcor's surprise, he says, some prescriptions continued to trickle in to treat the periodic flare-ups that plague people with multiple sclerosis.
So Questcor began hiring sales representatives to promote the drug for that use. Then it hired a sales force to promote the drug as a treatment for nephrotic syndrome, a kidney injury that can lead to kidney failure. In June, it began selling to rheumatologists.
For all these diseases, there are cheaper alternatives. Oral prednisone, which might be used for some rheumatological diseases, can cost $10 a month. Intravenous steroids, used to treat multiple sclerosis flares, cost several hundred dollars.
Because Acthar was approved for these conditions decades ago, Questcor has not had to do large clinical trials to show that the drug works. It has paid for some small studies, mainly by individual doctors, who then publish a paper that the sales force can present to doctors.
The study that justified calling on rheumatologists involved five patients with rare conditions, all of them treated by a single doctor. All the patients had much improvement on Acthar after failing to benefit from more standard therapies, the doctor, Todd Levine, said in a Questcor conference call.
Still, it appears that at least a couple of small studies that may have raised questions about the drug have been suspended.
"From my standpoint it just didn't work," said Dr. Sungchun Lee, a Phoenix nephrologist who stopped a small study testing Acthar as a treatment for nephrotic syndrome. "I think they were O.K. with me stopping because we weren't getting the results," he said.
Another study that was terminated sought to determine whether multiple sclerosis patients who did not have a good response to steroids should be treated with either another round of steroids or with Acthar. The study was halted midway through "to analyze data," according to the summary of the trial on the federal clinical trial database.
A negative result could have jeopardized already growing sales for multiple sclerosis. The company says the trial fell hopelessly behind its goal in recruiting patients.
Given the scarce data, and the high price, most doctors do not use Acthar for multiple sclerosis, nephrotic syndrome or rheumatology.
"It's absurd," says Dr. Douglas R. Jeffery, a multiple sclerosis specialist in Advance, N.C. "There's never a clinical setting where I can justify spending $23,000 to treat an M.S. relapse."
But some doctors say Acthar can be effective in cases that are not well treated by steroids. They say that there is emerging evidence that Acthar does more than just stimulate the body to produce its own steroids.
"It really looks like the ACTH does bring something different to the table that standard steroids don't," said Dr. Ben W. Thrower, director of the multiple sclerosis institute at the Shepherd Center, a hospital in Atlanta. Dr. Thrower, who is a paid speaker for Questcor, said his institute had tried Acthar for about 60 of its 3,000 patients, ones who did not respond to steroid treatment. Acthar made the symptoms subside in about half of them.
GIVEN Acthar's price, Questcor does not need many prescriptions to make a good business. A course of treatment for nephrotic syndrome can run $250,000, while a shorter treatment for a multiple sclerosis relapse typically costs $40,000.
Questcor sales representatives who are lucky enough or skillful enough to have a big prescriber in their territory can reap bonuses of $50,000 a quarter, according to former employees of the company.
Executives are paid well, too. In 2009, Mr. Bailey hired his daughter Kirsten Fereday as director of business analytics and evaluation, a job that paid $275,000 in cash and stock last year.
Mr. Bailey and Steve Cartt, Questcor's chief operating officer, say the company's marketing has been aboveboard and that the company is now starting to sponsor more studies. "This wasn't possible until the drug was financially viable," Mr. Bailey said.
Patients report mixed results. Sharon Keller of Austin, Tex., who has nephrotic syndrome, tried Acthar after two other drugs had not worked. But she stopped, she says, because side effects including mood swings and weight gain were "much worse than I'd ever experienced."
"I almost had to fight with my doctor not to push it on me," Ms. Keller, 59, says. She says her insurer was charged $130,000 for her drug, including a vial she did not use. "I have a Cadillac in my refrigerator," she says of that leftover vial.
ONE big uncertainty hanging over Questcor is competition. As an old drug without patent protection, Acthar would seem to be a sitting duck for generic rivals. And other versions of ACTH have been sold in the past.
Yet Questcor is now arguing that its studies show that Acthar, despite the "highly purified" in its name, actually contains other substances from the pig pituitary glands that account for some of its effectiveness. The company does not intend to say what those other ingredients are, thus making it extremely hard for a generic company to copy Acthar.
"Coca-Cola is not going to tell you what Coke contains, either," Mr. Bailey says.
Whether such an argument will work remains to be seen. Even if it does, competitors could still sell other forms of ACTH. Novartis, which sells a synthetic version called Synacthen in Europe, has applied for a United States trademark, a sign that the drug might be brought to this country.
A small Maryland company, Cerium Pharmaceuticals, recently won orphan-drug designation from the F.D.A. for Synacthen to be used to treat infantile spasms. But that does not necessarily mean that Cerium has the rights to the drug or intends to market it.
Cerium is run by Gregg Lapointe, a former Questcor board member. He declined to comment for this article.
Still, Synacthen, or other versions of ACTH, might have to go through lengthy trials before being approved, and would have to be approved for one disease at a time.
So there is at least a chance that Questcor might maintain its high-priced dominance for a long time. In the meantime, the company plans to systematically expand the marketing of the drug to treat other diseases, starting with those already on the label.
Given that Acthar has many potential uses, Mr. Bailey says, Questcor sees no reason to come up with other drugs. The company has been buying back its stock, helping to underpin the price, and recently said it would start paying a dividend.
"We'll take it where it goes," Mr. Bailey says of Acthar. "It's taken us to places we never expected."


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"When hands on the street are held out, it isn't always alms that are beggared; it's life, contact, touch, generosity of spirit…"
Ragged Company is about a group of homeless people who win the lottery (13.5 million) but can't collect because they don't have a fixed address! It's been on my to-read pile for ages but I bumped it to the top after the recent passing of this great Canadian author Richard Wagamese. Like Medicine Walk, this book is a real, elegant, earthy, funny, and gentle story well told. Parts of it are delicious reflective prose and though it isn't a quick read, I did fly through it and couldn't put it down. It is deeply compelling and healing as a human reflection on the meaning of 'home' but also is intriguing to see what happens to people when they suddenly have an unlimited source of money and go from getting enough for each day to having enough for each day. Wagamese explores the development of the inner lives of four homeless people, as well as the lonely jaded journalist who befriends them and the lawyer who helps them. They become a rather odd ragged company, but isn't that what all of us are in the end?
What does it mean to belong, to be needed, to be free, and to be in community? After reading this book I feel even more strongly that when giving to the homeless it should always include a gesture of human connection as well…get a name, have a brief conversation, give a blessing–do not allow them to be invisible. Do not make assumptions about them or consider them all alike–they each have a unique past and a story, as do we all. Wagamese turns our conventional ideas upside down and makes us think in new ways about winners and losers, rich and poor, bondage and freedom, love and friendship, value and worthlessness, support and community, faithfulness and rejection…all through a powerful story. Rest in peace Richard Wagamese. You have taught us that we are story and we are grateful.

subset: commoncrawl


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What to Drink on Halloween
If you're plotting a Halloween bash, you've probably already started thinking about your costume (and your dog's costume) and the deviled egg eyeballs you're going to prepare. Today, we'll help you get set up on the drinks front, from beer suggestions to scary DIY candy-flavored drinks to totally delicious pumpkin cocktails and other autumnal libations.
Pumpkin Beer
Even if you kinda hate pumpkin beer, Halloween feels like the right time to drink it. Here's our guide to five favorites that are on shelves this year, and our top picks from a taste test of 17 different options last year. We also asked our group of Certified Cicerones (think of them like beer sommeliers) which pumpkin beers are the best of the bunch. Here are their recommendations.
Or you can throw a homebrewing party and make your own! Here's the beginner-friendly recipe. (Be sure to stock up on bottled beer, too, since it won't be ready to drink yet.)
Matching Drinks and Candy
We've done some serious research into which drinks taste best when you're eating candy. (Warning: such ambitious taste tests usually end in a sugar coma and a stomach ache.) When you've actually got a glass in one hand and an Almond Joy in another, pairing isn't completely straight forward. But we have tips and suggestions to share, whether you're going with straight-up spirits, beer, or wine.
How to Pair Spirits and Halloween Candy
Sweet Wines to Drink With Halloween Candy
Which Beer Goes Best With Halloween Candy?
If you're looking for more advice on how to find great beer and dessert matches, this guide from Mike Reis is an ideal place to start.
Pumpkin Cocktails
Mixing pumpkin-flavored drinks is a delicate art: you want the pumpkin flavor to come across, without a weird texture. Incorporating pumpkin butter and pumpkin beer are two of our favorite tricks.
The Great Calabaza
If you're into smoky mezcal, this pumpkin cocktail will be your new favorite fall drink. The savory side of pumpkin is emphasized, while the drink stays fresh with just-squeezed orange and lime. Rim the edge of the glass with five spice salt to complete the effect.
Vampire Blues
Made with bourbon and nutty sherry, this drink gets its seasonal flavor from pumpkin butter, and a bit of spice from Angostura bitters.
The White Pumpkin
This spin on a White Russian starts with Kahlua and vodka, but gets added interest from Ramazotti, an amaro with strong notes of orange and cinnamon that goes fantastically well with pumpkin.
Great Pumpkin
Jim Meehan of PDT created this rich cocktail, sweetened with flavorful Grade B maple syrup, and shaken with a whole egg. The pumpkin flavor comes from pumpkin ale—Meehan uses Southhampton Pumpkin Ale, but you can experiment with your favorite brand.
Turkey and Sage Cocktail
Fresh sage adds herbal complexity to this high-proof bourbon drink, flavored with pumpkin butter and balanced out with fresh lemon.
More Seasonal Mixed Drinks
You shouldn't feel like you're tied to pumpkin for a fall celebration. If you really want to get into the Halloween spirit, consider a streak of 'blood spatter' on top of any cocktail's foamy layer (pomegranate molasses looks an awful lot like blood.) Here are a few variations on the theme.
Or focus on fall's other signature flavors:
3 Hard Cider Cocktails to Make at Home
12 Ways to Use Maple Syrup in Cocktails
11 Ginger Drink Recipes
3 Concord Grape Cocktail Recipes to Celebrate Fall
20 Ways to Use Apples in Cocktails
Or just make something with bourbon. Everyone likes bourbon.
If You Dare: Candy-Infused Booze
If you really want to wow (or, um, gross out) your Halloween party guests, look into creating your own candy-flavored spirits by infusing your favorite booze with a Hot Tamale or two. Some combinations work better than others (Junior Mints and tequila = yes, marshmallows + cachaça = terrifying) so be sure to read our guide before you get started.
Have a happy Halloween, everyone!
About the Author: Maggie Hoffman is a Senior Editor at Serious Eats, based in San Francisco. She founded Serious Eats: Drinks in 2011. You can follow her on Twitter @maggiejane.
All products linked here have been independently selected by our editors. We may earn a commission on purchases, as described in our affiliate policy.


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Death. An inevitable fact of life, but one that is usually spoken about in hushed tones and with sadness and awkwardness, right? Well, that is until now.
Caitlin Doughty, a licensed mortician with a degree in medieval history, kind of blows that theory out of the water. Caitlin deals with the topic of death boldly, factually and with humour.
Her book Smoke Gets in Your Eyes: And Other Lessons from the Crematory was published in 2014, but she started her YouTube channel Ask a Mortician in 2011, long before the release of the book, and she hasn't done just a video or two. Caitlin has produced more than 50 videos, some receiving in excess of 250,000 views! In her eccentric, entertaining manner, Caitlin addresses questions that many of us have wondered about but never felt comfortable enough to ask, even if we knew someone who could answer them. No topic related to death seems to be too weird or too uncomfortable for Caitlin to discuss.
Perhaps it is because of this that she has more than 650 reviews of her book posted on Amazon (a 4-1/2 star overall rating) or perhaps this success is due to our curiosity about the niche topic she so readily and easily explains with her insider knowledge, but I'd like to think that Caitlin is a perfect example of an author with an extensive author platform, established long before the launch of her book. She's ticked all the boxes for building an author platform by using an extensive number of social media networks, YouTube and a website to attract readers for her book.
Continue reading "Author Platform Example: Caitlin Doughty, Ask a Mortician"


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What is this project?
It is a project to install 735 feet of new concrete sidewalk on the north side of Mt. Comfort Road from City Limits to Hidden Creek Drive.
Why is it important?
This new segment will provide a completed connection to the existing sidewalks on Mt. Comfort Road.
What is the current status?
This project is Complete.
How is this project being funded?
Funding for this project comes from the Street Fund. The Street Fund is financed through two sources:
1) Turn-back revenues from the State of Arkansas. The State collects motor fuel taxes, which are returned to the City on a per-capita basis.
2) Turn-back monies received from the County Road Millage Tax. The City receives 80% of the road millage levied by the Quorum Court on real and personal property located within the city.


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The Source
Q&A: Denise King on campus wayfinding project
October 22, 2012
This summer, Facilities Services finished phase three of a multiphase capital project to improve campus wayfinding and signage at Lewis & Clark.
The Source caught up with Planning Specialist Denise King to learn more about the impetus for the project and the payoff for the improvements.
What was the impetus for improving wayfinding at Lewis & Clark?
Sometimes seemingly small things will trigger much larger changes, and such is the case of wayfinding on campus. I believe President Hochstettler had some initial problems finding his way around campus, and he charged Carl Vance with seeking a solution. Mr. Vance asked the assistance of a local but nationally renowned wayfinding consultant, Anderson Krygier, and then formed an L&C task force to look into the problem. The task force went through a discovery period and looked at all things associated with visitors coming to our campuses, including the following areas:
- The notion that wayfinding is more than just signage.
- The names we use for each campus.
- The ways we direct people to each campus and how we identify the perimeters of each campus.
- The way we direct visitors to specific locations on each campus.
This discovery period helped guide our next steps:
- Reinforce hierarchy with wayfinding.
- Place identifying gateways at primary entries.
- Place threshold markers at campus entries.
- Reintroduce gate numbers with updated directory information at street entries.
- Improve pedestrian and vehicle directional information.
Can you walk us through the phases of this massive project?
We realized that this was a big project and would probably not be considered for funding as it was, so we broke it into smaller, more manageable, phases.
In the first phase, we undertook a number of tasks:
- We repurposed our existing signs into campus threshold markers.
- We turned our roadway directional signs into numbered gate directional signs.
- We updated our "You Are Here" map graphics with additional visitor information and added key departments to various buildings' identification signs.
- We launched the construction of the much-needed path along North Drive from Lower Griswold to Upper Griswold.
- We opened Huddleson Lane south of Templeton to one-way traffic with a pedestrian path to solve some of our navigation difficulties.
This phase also ushered in the orange sandwich board signs that are seen at the entrance to each gate for temporary event information.
In the second phase, we added additional building identification signs along the interior campus roadways. Initially, when these signs were installed in the late 1990s, there was a big push to be a pedestrian campus. Thus almost all of the residence hall signs were set along the pedestrian side of the buildings. The downside of this strategy was that people driving up to a building—including parents and emergency responders—could not find the building they were looking for.
For the third phase, completed this summer, we beefed up our internal vehicle and pedestrian wayfinding directories. This included more information about where to find parking, and we added four additional "You Are Here" map kiosks Additionally, for better visibility, we added orange "lollipop"-style pylons to each map kiosk.
What were the desired outcomes of the project? Are you already seeing some of the benefits of the improvements?
More people are finding their way around the campuses, and giving directions is easier. I think bringing back the gate numbers (which disappeared during the 1990s campus wayfinding update) has made the biggest impact. Unfortunately this is still a very difficult campus to navigate and without a sign on every corner, visitors often need help finding their way. Probably the best wayfinding resource we have is our staff and students looking out for visitors and offering help.
What's on your wish list for future improvements to Lewis & Clark?
Currently I'm working on updating and standardizing our internal parking and regulatory signs, and eliminating unnecessary or repetitive signs. I'm also working with the City of Portland to revamp our ODOT directional signs to campus, and I hope to find a satisfactory location for a Lewis & Clark major gateway sign. We still need street signs at some of our internal campus intersections, and we are also looking into a Lewis & Clark wayfinding app that people could access from their smart phones. We will continue to tweak and refine the wayfinding process as we discover deficiencies and new possibilities.
Is there anything else you would like to add?
I would like to give credit to the Wayfinding Task Force and Anderson Krygier for making this a successful, fun project.
Task force members: Michael Ford, David Kelley, Denise King, Tom Krattenmaker, Tim O'Dwyer, Lisa Pogue, Carl Vance, and Clark Yeager.
Anderson Krygier team: Elizabeth Anderson, Cherry Britton, Abby-Sophia Always, and Mike Sauer.


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Minister with responsibility for Novopay Steven Joyce today provided an update on Novopay and announced measures to address the situation.
"Novopay is one of the largest payroll systems in Australasia covering approximately 110,000 people and 15 separate collective agreements. After meeting with the key parties involved over the past week, it is clear the issues it has are complex, that there is no quick fix, and problems will continue for some time," Mr Joyce says.
"Next week's pay round covers the beginning of the school year and the Ministry of Education and Talent2 are expecting further issues particularly with the start of a new secondary school teachers' collective agreement.
"I have made it clear to all parties that the on-going issues with Novopay are unacceptable and new measures are being put in place to provide timely solutions."
The new measures include:
Conducting a technical audit of the stability of the Novopay system and the data contained in it
o Technical review by Murray Jack of Deloitte, incorporating the results of the audit currently being undertaken by Ernst & Young on behalf of the Ministry of Education and an accelerated audit of a sample of schools.
Instituting a new Novopay Remediation Plan
o Led by the Novopay Management Board
o Will accelerate software stabilisation, monitoring and enhancements and improve customer service
o Will involve more resources, which the Government will initially provide on a contingency basis while reserving its contractual position with Talent2.
Undertaking active sector re-engagement
o Led by the acting Secretary of Education and the Ministry of Education
o Will use the Ministry's regional network to support schools, document their feedback and provide them with more information and training
o Revitalise a reference group, chaired by the acting Secretary, which will include senior members of education sector bodies to ensure on-going sector engagement and input into system enhancements.
Investigating a revised Contingency Plan
o Led by the acting Secretary of Education who has commenced dialogue with previous supplier, Datacom.
Establish a Ministerial Inquiry
o Going to Cabinet on Monday
o Intention is for the findings of the Technical Review to be fed into the inquiry, and for the inquiry to cover all aspects of the teacher payroll system from outset to present day.
o More details will follow next week.
"I appreciate the issues with Novopay are hugely frustrating for those affected and I understand the pressures school pay roll staff are under. I can assure them that everything is being done to resolve the issues as quickly as possible," Mr Joyce says.


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Ordinary Grace Book Review
Book Review by Ann Jonas, Tradebook Buyer - CSB/SJU Bookstores
this review was published in the St. Cloud Visitor
Ordinary Grace: A Novel by William Kent Krueger; Atria Books; March 2013; 307 pp.; $24.99
William Kent Krueger, author of the award-winning Cork O'Connor mystery series, has written a new novel, which is very different from his mysteries. Like most of the thirteen Cork O'Connor titles, Ordinary Grace is set in Minnesota. The book is a story of a murder in a small town, but rather than focusing on "whodunit," Ordinary Grace tells the story of that tragedy's effects on the town and its residents.
The story is narrated by Frank Drum, forty years after the murder occurs. Frank is thirteen years old that summer of 1961, and lives with his family in New Bremen, a fictional town in the Minnesota River Valley. As the book's prologue states "It was a summer in which death, in visitation, assumed many forms. Accident. Nature. Suicide. Murder." The book begins with the death of one of the town's residents, a young schoolmate of Frank, who is killed on the railroad tracks outside of town. Further into the story, Frank's older sister, a talented singer who is headed to Juilliard, is murdered.
The book portrays Frank as a young teenage boy and his little brother, Jake, who try to make sense of the recent happenings in their family and their town. Nathan, their father, is the local Methodist minister. Their mother, Ruth, resents her husband's choice to be a minister, and is seen as somewhat of a rebel because she smokes and doesn't seem to care about appearances.
Nathan is the source of much wisdom, offering faith and leadership during tough times. At his church's service right after his daughter's death, Nathan starts his sermon by stating "I confess that I have cried out to God, 'Why have you forsaken me?'" He proceeds to deliver a beautiful and profound message of hope and belief.
In Ordinary Grace, Krueger sends readers back to 1961, when the Minnesota Twins were playing their debut season and life in a small town included a soda fountain, barbershop, and church. According to Krueger, the book is definitely not autobiographical, but he did "tap the deep roots" of his own experience, having grown up during that time period in several small towns. Krueger states that setting the book during that era allowed him to examine memories and feelings from his adolescence, and to "explore themes that have been important to me all my life."
Clearly, those themes include wisdom and grace, along with faith and forgiveness. Krueger does a masterful job of capturing the voices of Frank and his brother. The characters and small town life seem authentic and perceptive. The book is powerfully written and contains many beautiful passages, including the scene when Jake, who stutters, delivers the blessing at the meal following his sister's funeral that is simple and perfectly spoken. Frank reflects: "That was it. That was all of it. A grace so ordinary there was no reason at all to remember. Yet I have never across the forty years since they were spoken forgotten a single word."
Krueger has stated that Ordinary Grace is the "best thing" he has ever written; "everything I know about storytelling" went into this book. The idea for the novel came to him a while ago, but he was under contract to write other books. The story "haunted him, in the way good stories will," and simply wouldn't go away. Readers of Ordinary Grace are grateful that Krueger persevered and delivered this extraordinary book.


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Antiretroviral therapy and early mortality in South Africa
Traitement antirétroviral et mortalité précoce en Afrique du Sud
Tratamiento antirretroviral y mortalidad temprana en Sudáfrica
Andrew BoulleI, 1; Peter BockII; Meg OslerIII; Karen CohenIV; Liezl ChanningV; Katherine HilderbrandVI; Eula MothibiII; Virginia ZweigenthalIII; Neviline SlingersVII; Keith CloeteIII; Fareed AbdullahVII
ISchool of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
IIAbsolute Return for Kids, Cape Town, South Africa
IIIDepartment of Health, Provincial Government of the Western Cape, Cape Town, South Africa
IVGroote Schuur Hospital, University of Cape Town, Cape Town, South Africa
VThe Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
VIMédecins Sans Frontières, Cape Town, South Africa
VIIInternational HIV/AIDS Alliance, Brighton, England
OBJECTIVE: To describe province-wide outcomes and temporal trends of the Western Cape Province antiretroviral treatment (ART) programme 5 years since inception, and to demonstrate the utility of the WHO monitoring system for ART.
METHODS: The treatment programme started in 2001 through innovator sites. Rapid scaling-up of ART provision began early in 2004, located predominantly in primary-care facilities. Data on patients starting ART were prospectively captured into facility-based registers, from which monthly cross-sectional activity and quarterly cohort reports were aggregated. Retention in care, mortality, loss to follow-up and laboratory outcomes were calculated at 6-monthly durations on ART.
FINDINGS: By the end of March 2006, 16 234 patients were in care. The cohort analysis included 12 587 adults and 1709 children. Women accounted for 70% of adults enrolled. After 4 and 3 years on ART respectively, 72.0% of adults (95% confidence interval, CI: 68.075.6) and 81.5% (95% CI: 75.786.1) of children remained in care. The percentage of adults starting ART with CD4
counts less than50 cells/µl fell from 51.3% in 2001 to 21.5% in 2005, while mortality at 6 months fell from 12.7% to 6.6%, offset in part by an increase in loss to follow-up (reaching 4.7% at 6 months in 2005). Over 85% of adults tested had viral loads below 400 copies/ml at 6-monthly durations until 4 years on ART.
CONCLUSION: The location of care in primary-care sites in this programme was associated with good retention in care, while the scaling-up of ART provision was associated with reduced early mortality.
OBJECTIF: Décrire les résultats à l'échelle provinciale et les tendances dans le temps du programme de traitement antirétroviral (ART) de la province du Cap-Occidental, 5 ans après son lancement et démontrer l'utilité du système de surveillance de l'OMS pour ce traitement.
MÉTHODS: Le programme de traitement a débuté en 2001 au niveau de sites « novateurs ». Un rapide passage à l'échelle supérieure de la délivrance du traitement a commencé début 2004, à partir essentiellement d'établissement de soins de santé primaire. Des données relatives aux patients entamant un traitement ART ont été recueillies de manière prospective dans les registres des établissements de soins, ce qui a permis de constituer des rapports mensuels d'activité et des rapports trimestriels de cohorte. Les taux de rétention sous traitement et de mortalité, ainsi que les nombres de perdus pour le suivi et les résultats de laboratoire ont été calculés tous les 6 mois sous ART.
RÉSULTATS: Fin mars 2006, 16 234 patients étaient sous traitement. L'analyse de cohorte a porté sur 12 587 adultes et 1709 enfants. Les femmes représentaient 70 % des adultes inclus dans l'étude. Après 4 et 3 ans sous traitement ART, respectivement 72,0 % des adultes (intervalle de confiance à 95 % : 68,0-75,6) et 81,5 % des enfants (IC à 95 % : 75,7-86,1) étaient encore sous traitement. Le pourcentage des adultes débutant le traitement ART avec une numération des CD4 inférieure à 50 cellules/µl est tombé de 51,3 % en 2001 à 21,5 % en 2005, tandis que la mortalité à 6 mois passait de 12,7 % à 6,6 %, baisse en partie compensée par l'augmentation du nombre de perdus pour le suivi (atteignant 4,7 % à 6 mois en 2005). Plus de 85 % des adultes dépistés présentaient une charge virale inférieure à 400 copies/ml tous les 6 mois jusqu'à 4 ans sous ART.
CONCLUSION: La dispensation par ce programme des soins dans des sites de soins de santé primaire était associée à un taux de rétention satisfaisant, tandis que l'élargissement du programme
était associé à une réduction de la mortalité précoce.
OBJETIVO: Describir los resultados y las tendencias temporales a escala provincial del programa de tratamiento antirretroviral (TAR) de la Provincia de El Cabo Occidental a los 5 años de su puesta en marcha y demostrar la utilidad del sistema de vigilancia de la OMS para el TAR.
MÉTODOS: El programa de tratamiento dio comienzo en 2001 a partir de establecimientos innovadores. La rápida expansión del suministro de TAR comenzó a principios de 2004 y se centró predominantemente en los servicios de atención primaria. Los datos sobre los pacientes que comenzaron el TAR se reunieron de forma prospectiva en los registros de los centros, a partir de los cuales se elaboraron informes mensuales transversales de actividad e informes trimestrales de cohortes. La retención en el sistema de atención, la mortalidad, las pérdidas para el seguimiento y las variables de laboratorio se calcularon considerando los periodos de 6 meses de TAR.
RESULTADOS: Al final de marzo de 2006 se estaba tratando a 16 234 pacientes. El análisis de cohortes abarcó a 12 587 adultos y 1709 niños. Las mujeres representaban el 70% de todos los adultos estudiados. Al cabo de 4 y 3 años de TAR, respectivamente, el 72,0% de los adultos (intervalo de confianza del 95%, IC95%: 68,075,6) y el 81,5% (IC95%: 75,786,1) de los niños seguían atendidos. El porcentaje de adultos que comenzaron el TAR con recuentos de CD4 inferiores a 50 células/µl cayó del 51,3% en 2001 al 21,5% en 2005, mientras que la mortalidad a 6 meses cayó del 12,7% al 6,6%, compensada en parte por un aumento de las pérdidas para el seguimiento (que alcanzó el 4,7% a los 6 meses en 2005). Más del 85% de los adultos analizados presentaron cargas virales inferiores a 400 copias/ml a intervalos de 6 meses durante los 4 años de TAR.
CONCLUSIÓN: La ubicación de la asistencia en los centros de atención primaria en este programa se asoció a una buena retención de los pacientes, mientras que la expansión del TAR se asoció a una disminución de la mortalidad temprana.
The national antiretroviral treatment (ART) programme in South Africa was launched in April 2004.1 However, for some years prior to this, demonstration projects had provided ART to HIV-infected individuals with advanced disease through government health services. Several projects were located in the Western Cape Province which, as a result, is able to report on outcomes up to 4 years after initiation of therapy. The first such project began providing ART in Khayelitsha in May 2001,2,3 followed by a project in Gugulethu in September 2002.46
Since inception, the clinical guidelines and approaches to monitoring used in the Western Cape Province have been in line with those recommended by WHO.79 The treatment setting is reflective of public sector health services in South Africa. A description of outcomes 5 years into this provincial programme, and after significant scaling-up of care, has relevance to what can be anticipated in South Africa and other similar settings in the region.
This paper demonstrates that robust and useful information can be generated using a basics-first, paper-based monitoring system, as recommended by WHO.10 There are some sites in the province that collect clinical data electronically and enhance these data for cohort surveillance and research. These are designated as sentinel sites and address particular clinical and epidemiological questions. This takes pressure off the remaining sites from having to institute complex monitoring systems and ensures that in the majority of sites only the information essential for management and programme assessment is collected.
The aim of this paper is to describe the key clinical outcomes in the Western Cape provincial ART programme, in patients on therapy for up to 4 years, and the evolution of the programme over a 5-year period. Secondary aims are to demonstrate the field utility of the WHO monitoring guidelines and the feasibility of scaling-up services through primary-care sites.
Programme description
The first project to routinely offer ART in the public sector and on a district-wide basis in South Africa was started in 2001 as a partnership between the provincial government and Médecins Sans Frontières in the Cape Town township of Khayelitsha. At that time, several local clinicians had already been involved in ART provision through clinical studies and private funding and were able to support this and subsequent initiatives. These early sites can be considered as " innovator sites" in as far as they were able to grapple with many of the logistics of setting up services in anticipation of a more rapid scaling-up of ART services. By the time the national programme was launched in South Africa in April 2004, there were 16 discrete sites offering ART in the province, eight of which were in primary care. At this time there were 2327 patients receiving ART. By the end of March 2006, there were 16 234 patients receiving ART (87% adults) across 43 sites, the majority being treated in primary-care settings (67% in clinics and community health centres, and 13% in district hospitals). Enrolment increased steadily over this time to reach 1000 patients per month, with seasonal decreases in enrolment each December (Fig. 1 and Fig. 2). Care was first offered as part of the primary-care HIV intervention for children in 2002, with follow-up for children in this analysis extending to 3 years. Children were defined as patients starting ART under the age of 14 years.
Patients were considered eligible for ART if they had a stage IV illness (excluding extrapulmonary tuberculosis) or a CD4 count less than 200 cells/µl. The adult regimens used throughout comprised two nucleotide reverse transcriptase inhibitors (NRTIs) and one non-nucleotide reverse transcriptase inhibitor (NNRTI). Initially, the NRTI backbone in Khayelitsha comprised zidovudine and lamivudine, but was later changed to stavudine and lamivudine in line with the national programme. Paediatric regimens varied, with NNRTIs and protease inhibitors being variously used with the NRTI backbone.
Six-monthly CD4 counts and viral-load testing were provided in the programme, together with safety monitoring according to the specific regimens. The protocol for changing to second-line therapy was two consecutive viral loads above 5000 copies/ml.7 All laboratory tests were conducted by the National Health Laboratory Services. CD4 counts were performed using the panLeucogating method.11 Viral loads were conducted using the NucliSens HIV-1 QT® assay, and later NucliSens EasyQ® HIV-1 assay (bioMérieux, Boxtel, the Netherlands) for which the upper limit of detection is just under 400 copies/ml, hence the use of 400 copies/ml as the definition of suppression in all registers and analyses.
Data collection and analysis
The routine monitoring system
Data analysed were collected through the routine monitoring system. This system is one component of a framework for the monitoring of the ART programme in the province (Fig. 3). Other components include observational cohort studies in sentinel sites, special studies to address priority clinical research questions, and a passive-stimulated pharmacovigilance reporting system.
Patients are entered into a register in the order in which they start ART. Monthly reporting is universal across the sites and comprises cross-sectional patient and enrolment totals (Fig. 1 and Fig. 2), the essential information required by managers to keep track of resource allocation and progress against targets. Quarterly cohort reports are also universal and are provided a quarter in arrears to allow sites to complete the ascertainment of outcomes before reporting. These reports are aggregated by starting quarter, as well as by 6-monthly durations on ART, allowing for cohort outcomes to be reported. The metrics reported on quarterly include regimen (first- or second-line), CD4 count, viral load and outcome (i.e. in care, transferred out, lost to follow-up, died).
When aggregating from the registers, the measure of advanced immune suppression at baseline is determined by the proportion of adults with a baseline CD4 cell count of less than 50 cells/µl and in children a CD4 percentage of less than15% of total lymphocytes. Immunological response during follow-up is determined by the proportion of patients tested with CD4 cell counts above 200 cells/µl or greater (20% in children) and virological response by the proportion of patients tested with viral loads below 400 copies/ml. All cohort analyses are limited to treatment-naive patients.
Data analysis
The monthly data are presented as cross-sectional monthly totals, whilst the quarterly data are presented as combined annual enrolment cohorts followed up until study closure. The monthly data cover April 2004 to March 2006, whilst the cohort data include patients enrolled between May 2001 and December 2005, followed until March 2006. Owing to the aggregate nature of the data, all data are presented as proportions with 95% binomial confidence intervals. The definition of " remaining in care" is patients who had had at least one visit in the preceding 90 days. Correspondingly, the definition of " loss to follow-up" is patients who had not had a contact with the health services for 90 days or more. The small number of patients who transferred their care to other sites are excluded in both the numerator and the denominator in the calculation of the proportions remaining in care, died and lost to follow-up. These measures are limited to those patients followed up for at least the full duration under analysis. In addition, the proportion of patients remaining in care is further described as KaplanMeier estimates based on weighted survival data derived from the count data. All analyses were performed using Stata statistical software version 9.0 (StataCorp. LP, College Station, TX, United States of America).
Overall, 12 587 adults and 1709 children were included in this cohort report, totalling 14 296 treatment-naive patients. This is a near-complete representation of all public-sector patients started on ART in the Western Cape Province by the end of 2005. Follow-up for the oldest quarterly cohorts extends to 4 years on treatment. A further 2.4% of patients were treatment experienced before starting ART, and were not included in this analysis.
The percentage of men starting ART has remained around 30% over the 5 years of enrolment in the province, with a very slight increase over time. The gender breakdown of children is not routinely recorded but reviews of paediatric sentinel site data reveal that the gender breakdown of children starting ART is roughly even. Overall, 22.7% of adults began ART with a CD4 count below 50 cells/µl while 45% of children started ART with a CD4 count below 15% of total lymphocytes.
After 4 years on ART, 76% of adults remained in care (Fig. 4 and Table 1). For each duration on ART, this absolute estimate was based only on the data for those patients who started that number of months previously. Using the weighted survival data, the KaplanMeier estimate of retention in care was 72.0% at 4 years on ART with a narrower confidence interval (95% confidence interval, CI: 68.075.6). A similar analysis of paediatric outcomes (Fig. 5 and Table 2) revealed 81.5% (95% CI: 75.786.1) of children remained in care after 3 years. If looking only at those children who had been in care for the entire 3 years, the estimate is comparable (82.4%). In both adults and children starting ART, mortality was highest in the first 6 months on therapy.
The first laboratory metric reported on is the proportion of tests that are done when they should be done. This is a proxy for quality of care. Results were received in the cohort system for four out of five patients who should have received these tests (Table 3). There is currently a slight drop-off in the test completion proportion as the duration on ART increases.
Looking at adult laboratory outcomes, of those tested, 90.6% of adults achieved virological suppression by 6 months on ART (Table 3). Although the proportion of patients on second-line regimens increases with duration on ART, and the data system does not distinguish which viral loads are done in patients on first-line versus those on second-line, for all patients combined this percentage remained at 85% or above until 4 years on ART. At 2 years on ART, 3.7% of adults were on second-line, rising to 17.9% at 4 years on ART. Combining all adult patients together, irrespective of the duration on ART, 1.3% of patients were reported to be on second-line regimens at the end of 2005. At the end of the first year on treatment, 74.7% of adult patients had attained a CD4 count above 200 cells/µl or greater, rising to 86.0% at 2 years on ART and 95.3% at 4 years on ART.
The proportion of children achieving virological suppression ranged between 70% and 80% during the 3 years' duration of follow-up (Table 3), while 7.4% had been changed to second-line by 3 years on ART. By 2 years on ART, 85.7% of children had achieved a CD4 greater than 20% of lymphocytes.
As the rate of enrolment increased in the province (Fig. 1 and Fig. 2), the severity of illness in patients starting ART decreased, evidenced by the lower proportion with CD4 cell counts below 50 cells/µl at ART initiation. In 2001 and 2002, half the adult patients starting ART had a CD4 count below 50 cells/µl, whereas this fell to 21.5% in 2005. This, coupled with the expansion of the programme into different communities, has seen mortality during the first 6 months on ART almost halved from 12.7% to 6.6% (Fig. 6 and Table 4). At the same time there has been an increase in the proportion of patients lost to follow-up. For patients starting ART in 2005, 4.7% had been lost to follow-up 6 months after starting ART.
This analysis, based on routine data from a paper-based monitoring system, has demonstrated good cohort retention at 4 and 3 years in adults and children respectively, combined with favourable immunological and virological responses to therapy. As fewer patients have over time started ART with very low CD4 counts, so too has the mortality in the first 6 months of treatment declined.
The antiretroviral services in the Western Cape Province are representative of the national programme in South Africa, with the prior experience of innovator sites providing the opportunity to anticipate clinical outcomes and challenges that will be faced in the national programme.
The accumulated experience of these sites enabled the province to rapidly scale-up treatment in terms of both sites and patients around the time that the national programme became a reality. It is estimated that, in the final year under review in this paper, half of those newly in need of antiretroviral therapy were able to access it in the province. The falling proportion of adult patients with extremely low CD4 counts at enrolment reflects the impact of this scaling-up of ART provision.
The concurrent halving in early mortality at 6 months on ART, which accompanied the improved immunological status of adults starting ART, suggests that the high early mortality that is characteristic of programmes in the region is in part mediated by the extreme disease advancement at enrolment. This concurs with studies that have been able to stratify outcomes based on CD4 count categories.2,5,12,13 Measures of the baseline CD4 count on enrolment may prove to be an extremely useful barometer of the extent to which programmes have caught up with the backlog in treatment in instances where the need for ART cannot be easily assessed.
A key limitation of this analysis, and all analyses of aggregate data, is the inability to stratify outcomes by individual baseline measures of disease severity. It is not possible from this analysis to determine if the decline over time in early mortality is fully mediated by measured improvements in the baseline clinical status of patients starting therapy.
Increasingly, patients lost to follow-up are outnumbering patients who are known to have died in developing country cohorts.14 For this reason we believe that retention in care is the most useful metric for reporting on programme effectiveness. Retention in care in this analysis at 3 and 4 years on ART demonstrates unequivocally the huge survival benefit conferred by the intervention. Most of the current simulation models that anticipate either patient numbers or the costs associated with ART have assumed a median of between 6 and 7 years survival on ART.15 The current data at 4 years, where 7 out of 10 adult patients are still in care, suggest that these estimates are not overoptimistic, especially since many of the patients lost to care may well subsequently return to care, given the very tight definition of loss to follow-up.
Using 90 days without a clinical visit as the definition of loss to follow-up enables programmes to rapidly identify changes in this parameter and respond appropriately. It also fits in very well with the quarterly cohort reporting ensuring that, when reporting one quarter in arrears, all outcomes can be fully ascertained. On the other hand, many analyses have used longer durations (up to 1 year) without contact with the services to define loss to follow-up.13
Notwithstanding the definition used, a higher proportion of patients were lost to follow-up in the first 6 months on ART in 2005 compared to previously. It is probable that clinic patient loads exceeding manageable numbers in some clinics are affecting this. It is clear that retaining patients in constant care will become increasingly difficult as the service continues to expand, highlighting the importance of adherence promotion extending beyond the health services to the national and local media, political, social and religious platforms, as well as through community interventions. Decentralization of care to more facilities, and the appropriate resourcing of services, are key to ensuring that services at individual facilities remain of a manageable size and are able to appropriately retain patients in care.
Even though most services retained some capacity to actively follow up patients lost to care during the period under review, it is probable that there remains residual under-ascertainment of mortality in the latter years as loss to follow-up increased.16 It is further unknown to what extent in future the increased loss to follow-up will result in intermittent care and consequently increased virological resistance due to repeated treatment interruptions (which are known to be strongly associated with resistance).17
The slower increase over time in the numbers of children on ART compared to adults is entirely anticipated and does not imply that children are being underprovided for. Whereas the number of adults newly needing ART increases year on year, the number of children is decreasing due to successful implementation of a prevention of mother-to-child transmission programme.18,19
The virological outcomes are encouraging and suggest that at a population level the rates of viral rebound have not been alarming and are not undermining overall programme success. Nevertheless, with up to one in five patients requiring second-line therapy by 5 years on ART, it is clear that the higher cost of second-line drugs will impact on total programme costs as programmes mature.20
There have been many lessons learned in implementing the WHO monitoring approach. This system, based on registers and regular cohort analyses, shares many attributes with systems that have been in use for many years for monitoring tuberculosis programmes. Worth noting is the value of differentiating sentinel from routine sites,21 liberating the majority of sites from onerous data-collection procedures that are designed for clinical research rather than for supporting routine care. It has been our experience that, with viral loads being available, managers have paid little attention to CD4 count outcomes in assessing programme performance. We have also found that presenting the completion proportions for laboratory outcomes is an invaluable metric over and above the outcomes themselves in the subset of patients for whom results are available. Finally, one of the major challenges emerging as models of care evolve is the large number of patients moving between facilities, who, once transferred out, are censored in the cohort analyses.
The ability to report on cohort outcomes without electronic systems underscores the value of implementing a basics-first approach to routine monitoring. This does not mean that there is no role for the progressive and measured development of electronic systems22 but rather that the basic building blocks that are required for a paper-based system are the same measures that will make electronic systems a success.23
Perhaps the most important lesson from the first 5 years of this programme is that implementing an ART programme in primary-care facilities from the outset is feasible and can achieve excellent clinical results. It is probable that the location of care in community clinics is one of the key factors contributing to the retention of patients in care.24
Looking to the future, if the Western Cape Province is to come close to the stated target of treating 80% of patients newly in need of therapy each year over the coming years, the annual number of patients enrolling in care will need to double while the total number of patients in care quadruples over a 5-year period. This will require even further task-shifting and expansion of the service platform, given that enrolment is already threatened by capacity constraints in the existing service platform.25
In conclusion, this paper has demonstrated excellent clinical outcomes 5 years after the Western Cape Province began offering ART in the public sector, validating the decision to make this a primary-care intervention from the outset. The WHO monitoring system has enabled the province to keep track of the intervention and of the performance of individual sites, while allowing space for more complex and durable solutions to be developed for the larger sites.
Funding: The following organizations have provided support in whole or in part to various of the authors during the study period: the Provincial Government of the Western Cape; Médecins Sans Frontières; the Global Fund to fight AIDS Tuberculosis and Malaria; NIH grant U01 AI069924-01.
Competing interests: None declared.
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10. Patient monitoring guidelines for HIV care and antiretroviral therapy (ART). Geneva: WHO; 2006. Available from: http://www.who.int/3by5/capacity/ptmonguidelinesfinalv1.PDF [accessed on 16 October 2007] .
11. Glencross D, Scott LE, Jani IV, Barnett D, Janossy G. CD45-assisted PanLeucogating for accurate, cost-effective dual-platform CD4+ T-cell enumeration. Cytometry 2002;50:69-77. PMID:12116348 doi:10.1002/cyto.10068
12. Stringer JS, Zulu I, Levy J, Stringer EM, Mwango A, Chi BH, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296:782-93. PMID:16905784 doi:10.1001/jama.296.7.782
13. Braitstein P, Brinkhof MW, Dabis F, Schechter M, Boulle A, Miotti P, et al. Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet 2006;367:817-24. PMID:16530575 doi:10.1016/S0140-6736(06)68337-2
14. Rosen S, Fox P, Gill C. Patient retention in antiretroviral therapy programs in Sub-Saharan Africa: a systematic review. PLoS Med 2007;4:1-11. doi:10.1371/journal.pmed.0040001
15. Boulle A, Kenyon C, Abdullah F, Moatti JP, Coriat B, Souteyrand Y, et al. A review of antiretroviral costing models in South Africa. Economics of AIDS and access to HIV/AIDS care in developing countries. Issues and challenges. Paris: ANRS; 2003 pp. 293-310.
16. Yu JK, Chen SC, Wang KY, Chang CS, Makombe SD, Schouten EJ, et al. True outcomes for patients on antiretroviral therapy who are " lost to follow-up" in Malawi. Bull World Health Organ 2007;85:550-4. PMID:17768504
17. Oyugi JH, Byakika-Tusiime J, Ragland K, Laeyendecker O, Mugerwa R, Kityo C, et al. Treatment interruptions predict resistance in HIV-positive individuals purchasing fixed-dose combination antiretroviral therapy in Kampala, Uganda. AIDS 2007;21:965-71. PMID:17457090 doi:10.1097/QAD.0b013e32802e6bfa
18. Abdullah MF, Young T, Bitalo L, Coetzee N, Myers JE. Public health lessons from a pilot programme to reduce mother-to-child transmission of HIV-1 in Khayelitsha. S Afr Med J 2001;91:579-83. PMID:11544974
19. Coetzee D, Hilderbrand K, Boulle A, Draper B, Abdullah F, Goemaere E. Effectiveness of the first district-wide programme for the prevention of mother-to-child transmission of HIV in South Africa. Bull World Health Organ 2005;83:489-94. PMID:16175822
20. Cleary SM, McIntyre D, Boulle AM. The cost-effectiveness of antiretroviral treatment in Khayelitsha, South Africa a primary data analysis. Cost Eff Resour Alloc 2006;4:20. PMID:17147833 doi:10.1186/1478-7547-4-20
21. The Western Cape Antiretroviral Programme: monitoring report. Cape Town: Provincial Government of the Western Cape; 2006. Available from: http://web.uct.ac.za/depts/epi/artrollout/files/Artmonitoringreport_wc_062006.pdf [accessed on 16 October 2007] .
22. Tierney WM, Beck EJ, Gardner RM, Musick B, Shields M, Shiyonga NM, et al. Viewpoint: a pragmatic approach to constructing a minimum data set for care of patients with HIV in developing countries. J Am Med Inform Assoc 2006;13:253-60. PMID:16501175 doi:10.1197/jamia.M2005
23. Harries AD, Gomani P, Teck R, de Teck OA, Bakali E, Zachariah R, et al. Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model. Trans R Soc Trop Med Hyg 2004;98:695-701. PMID:15485699 doi:10.1016/j.trstmh.2004.05.002
24. Pienaar D, Myer L, Cleary S, Coetzee D, Michaels D, Cloete K, et al. Models of care for antiretroviral service delivery. Cape Town: University of Cape Town; 2006. Available from: http://web.uct.ac.za/depts/epi/artrollout/ [accessed on 16 October 2007] .
25. Boulle AM, Coetzee DJ. Anticipating future challenges to ART provision in South Africa: reflections on the Khayelitsha ART programme. Acta Academic University of the Free State 2006; Suppl 1;241-55.
(Submitted: 25 June 2007 Revised version received: 17 October 2007 Accepted: 27 November 2007 Published online: 6 May 2008)
1 Correspondence to Andrew Boulle (e-mail: email@example.com).


text: We have countertop devices that blend, toast, and bake bread. We can make our own wine at home, and there are even machines to make beer at home. So it didn't seem completely implausible this past week when the story spread across the newsphere that you could toss a few ingredients in a machine no larger than an electric kettle and pour out some lovely wine only a few days later. Just very implausible. And it was. [More]


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1 Dozen Maxfli U/6
$ 17.99
Maximize playability and performance with U/6 Golf Balls. These 6-piece golf balls feature 4 progressively dense mantle layers for straight flight and high Moment of Inertia at impact. The new Tour-proven performance urethane cover features Tri-Di dimple technology and delivers penetrating, aerodynamically sound ball flight. A resilient, low compression core gives Maxflireg; U/6 Golf Balls increased distance for golfers with normal swing speeds.


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Woolrich follows stringent ethical policies for the use of any animal-derived materials in its products, and assures the highest degree of attention to consumer's health, as described in this document.
Woolrich respects and believes that choosing to wear garments made with fur, down or other animal-derived material is a personal decision. Woolrich recognizes that animals are sensitive beings and should be respected and always be treated in such a way that they do not suffer.
The Company's approach is to ensure that animal-derived products are sourced from animals that have not been subjected to any unfair or unethical practices, and to provide customers with the most complete and transparent information about animal-derived materials used so that they may make their own conscious choice. For those customers who choose not to wear animal derived-products, Woolrich also produces alternative synthetic options, devoid of any animal component.
Woolrich is committed to important long-term investments in order to assure the application of dedicated control procedures and the complete traceability of the source of the animal-derived materials from farm to factory, Involving independent internationally accredited certification bodies.
The Company currently manages the selection of 100% of the fur used in its garments. This allows the Company to check and control the source, quality and certification of all the fur used in its collection.
The Company uses only animal-derived products from suppliers that can prove that the fur has been obtained according to the international rules for animal care and protection and the utmost ethical and legal practices.
All of the products sold by Woolrich comply with the following international conventions, laws and regulations outlining the standards for animal protection:
• The Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES), implemented by European Regulation n. 338/1997, ensures that international trade does not threaten the survival of any animal species;
• European Regulation n. 3254/1991 prohibits the use of leg hold traps and forbids the introduction into the European Union of pelts and manufactured goods of certain wild animal species originating in countries that do not meet international humane trapping standards;
• European Regulation n. 1523/2007 prohibits the sale, import and export of cat and dog fur and products containing such fur;
Moreover, more than 90% of the fur used is manufactured by the most skilled Italian fur manufactures. These artisans come from families with a heritage of expertise who share the Company's constant commitment to the highest standards.
Here are some more details about each fur type, down and feather:
Raccoon & Fox Fur
All Raccoon and Fox fur used by Woolrich is of the Finland variety and has been bought through the renowned and certified Saga Furs Auction House. Saga Furs offers Finland Raccoon collections coming exclusively from certified farmed furs. To become certified, a farm must meet 32 requirements that range from well-being and animal health to farm hygiene and training for all possible conditions. The Saga Certification hangtag on the garment assures consumers and certifies the fur item in question.
Coyote Fur
All Coyote fur used by Woolrich comes from professional and reliable Canadian trappers and hunters. The community of Canadian trappers and hunters relies on the Coyote for food and income; therefore, its practices reflect its respect for nature and desire to keep this animal species sustainable for generations to come, assuring that endangered species are never used. Moreover, Canada sets the standard in trapping methods, as a basis for the Agreement on International Humane Trapping Standards (AIHTS).
Rabbit Fur
All Rabbit fur used by Woolrich comes from the by-product of the food industry, and not from animals raised for fur. The Company sources Rabbit fur only from reliable selected suppliers that can assure that animals are treated according to the utmost ethical and legal practices set by World Organisation for Animal Health (OIE) and European Convention for the Protection of Animals Kept for Farming Purposes, implemented by the European Directive n. 98/58/EC.
Down and Feathers
All of the down and feathers used in Woolrich products are from duck, which is a by-product of the food industry. The company has reached 100% traceability of down and feathers supply chain, through the certification issued by IDFL, a global leader institute in testing and inspecting filled product according to the standards established by the European Down & Feather Association (EDFA). By this certification it is assured that down or feathers used by Woolrich come only from farms that guarantee the welfare of their animals, and do not come at all from live plucking, force-feeding, or any other activity that mistreats animals. Woolrich currently offers down jackets with a high Fill Power (FP) value, according to the measurement system used by the International Down & Feather Bureau (IDFB). This assures consumers of the quality of down products (the higher the fill power, the more insulating value the garment will provide). The current average values are FP 600 for 70/30 duck down, FP 650 for 80/20 duck down, and FP 740 for 90/10 duck down. Each item is subjected to testing that constantly monitors the fill power throughout production.
For Woolrich, it is essential to have complete confidence in the quality and safety of all products put on the market, and to assure the protection of the health of its customers by avoiding the presence of any harmful chemical substances in garments.
Woolrich already complies with all international laws and regulations concerning the safety of the products, and deals only with qualified suppliers. Even going beyond what is required in order to ensure the highest possible level of quality and safety of its products. Woolrich has implemented more stringent quality and safety standards by adopting a Restricted Substances List (RSL) that specifies the chemical requirements applicable to all the materials and the final products, and which is constantly updated and improved according to most advanced European, International law and voluntary regulations.
Moreover, in order to ensure that each product consistently meets the required quality and safety standards, Woolrich has created a special Testing Program. Suppliers are required to carry out regular tests in close collaboration with Woolrich and nominated third party international accredited testing laboratories.
This Testing Program assures that component materials (such as fur or fabrics) are checked during various phases of the manufacturing process, and that only finished products that meet all the quality and safety requirements are included in the Woolrich collection and offered to the consumers.
Woolrich strongly believes that children need special attention, and the garments they wear must provide an extremely high level of safety, enabling them to play without risk of foreseeable injury, such as strangulation, choking, inhalation and ingestion, as well as other potential physical hazards.
Woolrich design and quality control staff is aware and updated on current children safety regulations and the assessment of safety requirements applies initially to children's products during design and development phases and relates particularly to laws and regulations from major regions such as the EU, US and Japan:
• Cords and Drawstrings: EU-EN14682:2014, US-ASTM F1816, JP-JIS L4129.
• Small Parts: US-16CFR1501 and EU-EN71-1.
• Sharp Points and Sharp Edge: US-16CFR1500.48-49
• Flammability of Clothing Textiles: US-16CFR1610 and 16CFR1611
• Total Lead Content and Lead in Surface Coating: US-16CFR1500 and 16CFR1303
Woolrich is committed to respecting all human rights, as articulated in the Universal Declaration of Human Rights, the International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights, the Conventions on Children's Rights, and the International Labor Organization's (ILO) Declaration on Fundamental Principles and Rights at Work.
Therefore, Woolrich expects all its business partners, including suppliers and independent manufacturers, to adopt and adhere to this undeniable values, ensuring that any exploitative, inhumane, unsafe or unhealthy conditions and all forms of discrimination and any use of child labour is unequivocally excluded.
Woolrich implements its commitment working closely with its business partners, suppliers and independent manufacturers, enforcing it as a fundamental condition of the business relationship.


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The Rays square off against Seattle this weekend. So get your butt on the No Excuses Tour chauffeured luxury bus to Tropicana Field, courtesy of Paradise Worldwide Transportation and Lee Roy Selmon's.
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They say that friends should never live together or start a business, because it'll ruin the friendship. We've seen it happen. Good buddies who decide to split the rent on a nice apartment, only to find themselves at each other's throat within a couple of months. A pair of lifelong pals who start a restaurant or an online venture and eventually wind up on opposite sides of a nasty lawsuit.
So when Brett Battles suggested that we write a book together, I found myself hesitating. Just for a moment. The idea seemed like a good one—a great one, in fact—and after that initial hesitation, I readily agreed. But a quiet, somewhat nervous voice in my head kept saying to me, "What if this doesn't work?"
Brett and I have known each other for several years now. We met online through our blogs and through Killer Year, the author collective that Brett founded with a few of our friends. There were about thirteen of us, and we all had debut thrillers coming out in 2007, so we decided to band together, brand ourselves, and cross promote. And for a while there, Killer Year was kind of a big thing in the thriller world.
At Thrillerfest Arizona, the first and (to my mind) the best of the Thrillerfests, Brett and I finally met in person and found ourselves bonding like brothers. In fact, people sometimes mistake us for brothers, which amuses—and sometimes annoys—both of us. So, several solo books later, we agreed it was time to collaborate.
But what would the book be about?
It took us nearly two years to figure it out. We kicked around a couple of ideas—one based on an old TV pitch of mine called LINGER—but neither of them caught fire. Then one day Brett said, "Hey, you know that series concept you had about a kick-ass female bounty hunter who gets recruited to infiltrate a women's prison in Europe? Why don't we do that one?"
I did remember, of course. It was one of those back burner ideas that I'd never gotten around to writing, so it seemed like the perfect fit for us.
The question, however, was how exactly were we going to do this? I still had the niggling concern about ruining our friendship, because, let's face it, we're both pretty opinionated guys. What would we do if we got in the middle of this thing and started to clash on the direction of the story?
But the immediate question was logistics. We have friends who have collaborated by using Google Docs, working live, over the web, writing and rewriting at the same time. But that process seemed like a nightmare. And since sitting down side by side was pretty much impossible—we live in different cities—how would we write this damn thing? Would we alternate chapters? And what about the difference in writing styles? Would it be evident to the reader?
What we ultimately decided to do was alternate drafts. The idea was conceived as a series from the very beginning, so we'd make sure to do a detailed outline first (something neither of us do when working solo), then one of us would take the outline and run with it, hammering out a first draft.
Once that draft was done (with a lot of phone calls in between), the other would come in and do a rewrite, then the final polish would be left in the hands of the original writer. And with the next book, we'd simply reverse roles.
It was a good strategy, but I was still concerned about possible friction between us. To his credit, Brett says he was never worried about it, but I had been in a couple of less than perfect collaborative situations in the past, and was a little gun shy. So, right from the start I told Brett that we both needed to check our egos at the door. We needed to treat this book as if it were a solo project and be as ruthless with each other's writing as we are with our own—no hard feelings allowed.
Brett agreed, and fortunately, my concerns turned out to be much ado about nothing. The process was so smooth and conflict free that it seemed almost effortless. From the very beginning Brett and I were in agreement on every scene, every character motivation, every plot conflict, and when one of us came up with a change, the other readily welcomed it.
Voice was also never a problem. It got to the point where we'd read a draft and couldn't remember who had written what.
In many ways, the collaborative process was better than writing solo because I now had a sounding board that was just as invested in the outcome as I was. And through it all, we've still managed to remain friends. Good friends. In fact, we're both looking forward to working together again, writing the next book in the series.
So I guess Brett and I are proof that what "they" say isn't always true.
Or maybe we just got lucky.
I met both Rob and Brett at that first Thrillerfest in Arizona and I concur–it was the best conference ever. Rob and Brett are both amazing men and talented writers. I'm so excited they came to visit today at Murder HE Writes! You can check out their websites and books here: Rob, Brett — ask any question you want! They'll both be around to chat. I for one was fascinated by this process — especially how two organic writers ended up plotting out a book together!


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When a couple gets married, they usually enjoy sharing their successes with one another, regardless of how big, small—or embarrassing they are.
That's not the case for former '90s heartthrob Brian Austin Green, 38, who has a mutual agreement with his wife, actress Megan Fox, 25, not to watch each other's work—ever.
Fox, who's been busted for covert attempts to catch old "90210" episodes, has had trouble keeping up her end of the deal.
U.S. & World
"She tries to sneak them on SOAPnet," Green told New York Magazine's Vulture. "And then she gets in trouble for it. We have a rule: We don't watch each other's stuff."
Thirteen years his junior, it's fair to say Fox is more of a "Dawson's Creek" kind of gal anyway.
No word if she's seen any of Green's infamous rap videos though.
Fox's last film, "Passion Play," which co-stars Mickey Rourke and Bill Murray, grossed just $3,669 at the box office. Chances are her hubby, unlike Fox, didn't break their rule and check it out.


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2001 CHEVROLET BLAZER Review - Base Price $19,170
The Blazer marches on.
Blazer is not the newest mid-size SUV you could buy. Indeed, Chevy is launching the all-new 2002 TrailBlazer, a bigger four-door model to better compete with the Ford Explorer. But the Chevy Blazer still has a loyal following, particularly among younger buyers, and it will continue to be sold until 2003. The Blazer remains a competent vehicle and it costs much less than the new models.
Expect to step up to get in the Blazer. Though not as radical as larger 4x4 rides, the Blazer has a higher seating height than the typical sedan. The payback is that commanding view of the road that SUV owners cherish.
Inside, the LT features standard "premium cloth" high-back bucket seats with eight-way power standard for the driver. Power is optional for the front passenger seat, and two-setting memory seat adjustment is available for the driver's seat.
The front seats are broad with limited bolstering. They are more like comfortable chairs than sports-car bucket seats. An annoying bulge in the front passenger's footwell accommodates the Blazer's exhaust. The rear bench is low; it is comfortable for two adults, though three will fit. The rear seatback splits and folds 60-40 for cargo flexibility.
The Blazer comes with full instrumentation that is well laid out; it shares its instrument panel with GM's other Blazer-class trucks. General Motors has made major strides in its minor controls, and the dash of the TrailBlazer is an excellent example. The switches, knobs and levers for the heating, ventilation, air conditioning and audio controls look and feel good and don't require a correspondence course to learn how to operate.
The LT also includes a leather-wrapped steering wheel, remote keyless entry, power locks and windows, power heated mirrors, rear window defogger and wiper, cruise control and lighted visor mirrors. Tilt wheel, two auxiliary power outlets, AM/FM stereo with CD player, and an overhead console with an outside temperature readout are also standard. New for 2001 is OnStar, GM's remote communications system, standard on LT and TrailBlazer. Air conditioning is standard on all Blazers, with automatic climate control optional on the LT and standard on TrailBlazer.
Chevy Blazer is a traditional SUV, all truck with separate body-and-frame construction. Variations in the grille, bumper, and wheels distinguish one trim level from another.
All Blazers are powered by a 4.3-liter Vortec V6. This 90-degree V6 has a cast-iron block and head and overhead valves, and runs happily on 87 octane gasoline. Although redlined at 5600 rpm, it reaches its peak 190 horsepower at 4400 rpm. And, with a very useful 250 pound-feet of torque at 2800 rpm, there's little need to rev it into the red. GM's four-speed electronic automatic transmission is standard on four-door Blazers, although a five-speed manual transmission is available on the two-door models.
The four-wheel-drive Blazer LS comes with push-button Insta-Trac, which allows shift-on-the-fly between 2WD and 4WD. The more sophisticated Autotrac four-wheel-drive system is optional on the LS and standard on LT and TrailBlazer. Autotrac combines the best of full-time and part-time 4WD by adding an "Auto 4WD" button. In this mode, the transfer case remains in 2WD until wheel slip is detected. An electric servo then shifts the transfer case into 4WD until prop shaft speeds are equalized, and then returns it to 2WD. If multiple "slip events" are detected, the transfer case remains in 4WD for a longer time. Autotrac also has a transfer case neutral position for towing behind a recreational vehicle.
All Blazers use a short-/long-arm front suspension and a live axle on leaf springs at the rear (variable-rate, multi-leaf springs on TrailBlazer). 4x4 models are sprung by torsion bars up front, while 4x2's have coil springs. Last year's optional Smooth Ride Suspension is no longer offered, so most Blazers come with the Z85 Touring Suspension. Using firm de Carbon shock absorbers and stiffer spring rates, the Z85 package has a more controlled ride than the old Smooth Ride Suspension. The only suspension variations available in 2001 are the super-heavy-duty ZR2, and of course the street-performance Z87 suspension that comes exclusively with Blazer Xtreme. ZR2 substitutes stronger parts throughout the chassis, plus skid plates, a track bar for the locking rear axle, a 3.9-inch wider tread and stiffer springs with Bilstein gas-pressure shocks.
Aluminum wheels are standard on all Blazers, differing in design according to model. Four wheel disc brakes are standard, and the braking system was upgraded for the 2000 model year.
The engine fires off eagerly with a twist of the key and settles to an idle that's steady but telegraphs some of the basic imbalance of a 90-degree V6. That smoothes as revs increase, and in the operating range between 2000 and 3000 rpm the Vortec is a friendly companion. Full throttle causes the V6 to accelerate with a healthy growl that gets louder as revs rise. The Blazer's acceleration is more than adequate to keep up with traffic.
The standard Touring suspension is very much in touch with the road, a characteristic not everyone will appreciate. But the reward is an easily discernable improvement in responsiveness, a reduction in float and, thanks to greater roll resistance, less lean in the corners. The result is an overall greater feel of control and confidence at the minor cost of a slightly bumpier ride.
The Auto 4WD mode can be used at all times. It keeps the transfer case in two-wheel drive until slip occurs, so there's no fuel-mileage penalty. Yet it reacts instantly to loose gravel or wet or icy pavement, shifting seamlessly into four-wheel drive. If there's any shortcoming in the system, it's that the driver isn't alerted when the system is shifting into four-wheel-drive mode (as on cars that use warning lights to indicate when traction control is functioning).
Out on the Interstate, the Blazer cruises effortlessly. The V6 operates in the low 2000-rpm range at highway speeds and, except for a subtle bass-line from the engine and a steady road rumble up through the suspension, the ride is quiet enough for easy conversation between front and rear passengers. The tires selected by Chevrolet are free of whine and aren't so heavy as to overwhelm the suspension. A slight whisper of wind noise around the A-pillars is the only other distraction. The ride, though firm, is not at all harsh or jiggly. Not all sport utilities are this civilized over the road, and we wouldn't hesitate to drive a high-mile day in the Blazer.
Loading for a big trip would be easy. Access to the commodious cargo compartment is via a rear liftgate. A cargo cover is standard; unlike those that require you to climb into the cargo area to unreel them, the Blazer's cover goes from side to side. Nothing is in the way when you want to lower the rear seats to load large items: the cover reel need not be removed and become itself another piece of cargo. And with the spare mounted under the rear, a flat tire won't mean unloading your load.
The Blazer is one of the reasons so many people use a sport-utility in place of a car. It will do everything a car will do, and almost as well. Plus it adds almost unstoppable mobility in the worst weather and the capability to go where the roads don't. The LT offers a long list of standard equipment popular with buyers, meaning no excuses in day-to-day use or when trading it in. Although with a list like the Blazer's, that day won't have to come too soonàunless it's to step into the Blazer's replacement.
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